CHAPTER 10 Integumentary System^403
- Oral antibiotics may be necessary.
- Administer pain medications (oxycodone, morphine) as needed, especially
before dressing changes that may be painful. - Prevent heat loss due to large areas of tissue exposed from lack of skin
coverage. - Maintain fluid levels since fluid loss is common from evaporation and
wound drainage.
NURSING DIAGNOSES
- Risk of fluid volume deficit
- Pain, discomfort
- Risk of altered body temperature
NURSING INTERVENTION
- Anticipate pain medication needs to make the patient more comfortable.
- Assist in range of motion to avoid contracture development due to pain with
movement. - Encourage family visitation.
- Assist with activities of daily living.
- Isolation may be needed to protect the patient from bacteria, especially if a
large amount of skin is not intact. - Teach the patient to look for signs and symptoms of infection: fever, increased
redness, increase in drainage, or change in color of drainage.
Dermatitis
WHAT WENT WRONG?
Inflammation of the skin as a result of contact with an irritating substance such as a
chemical, foreign substance, medication, or contact with a plant, such as poison ivy.
The skin may become reddened, irritated, and itchy. The usual causes are allergic
reactions. Often the patient has a history or a family history of asthma, allergy, or
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